24 November 2010

Stickler Syndrome -Part 1

Left: Gunnar Stickler, MD; Right: Michael Shapiro, MD.












This post is dedicated to Gunnar B. Stickler

Dr Stickler was born June 13, 1925 and died on November 4, 2010. Stickler syndrome remains an important cause of pediatric (and adult) blindness that can be largely prevented. His landmark paper was HEREDITARY PROGRESSIVE ARTHRO-OPHTHALMOPATHY. STICKLER GB, BELAU PG, FARRELL FJ, JONES JD, PUGH DG, STEINBERG AG, WARD LE. Mayo Clin Proc. 1965 Jun;40:433-55.  
I had the pleasure to meet him in 2006. In this photograph I am sitting with Dr Stickler. 
I want to extend a special thank you to Stickler Involved People (SIP) for inviting me to their conference.
A RetCam photograph of a Stickler Disease eye in a young boy at presentation.  It shows a long-standing Giant Retinal Tear with a scrolled edge is seen on the left side and fixed folds around a funnel detachment with a hazy view.  This Giant Retinal Tear is complicated by Proliferative Vireoretinopathy.
Two weeks ago I repaired the retina of a child with clinical stickler disease who had a long standing Giant Retinal Tear and severe PVR. He is pretty typical for about 25% of the cases in children under 12 years of age and probably a larger percentage in even younger kids. They loose their vision but do not really know that it is something to report because it is painless and they can use the other eye. At some point the blind eye will come to the parents attention. In some cases, a minor injury may raise the question about the vision or cause pain that leads to an examination. In other cases, the detached retina cases the eye to degenerate with a cataract, redness and irritation or reduction in size with a drooping lid. Any of these late complications may also bring parental attention to the eye. Late complications usually indicate a poor prognosis for visual recovery.


I did the surgery and the retina has attached, but the vision is very poor because of the long period of detachment. The retina had a retinal cyst which is bad. I hope for improvement, but the general prognosis for this eye is quite guarded.

Fixing a retinal detachment of this sort is challenging and there are some technical issues of interest to retinal surgeons. However, the two major issues regarding Stickler Disease are first, diagnosis and second, prevention.

The biggest worry is the second eye. It has a risk of retinal detachment in the range of 50-70% which is astronomical when compared with the .01% risk in the general population. I prescribed a treatment with laser for prophylaxis.

I perform the prophylactic laser treatment from the ora serrata in a near confluent manner for about 8-12 rows. I will also treat through and around lattice. However, in truth the manner of the prophylaxis remains unresolved. Martin Snead has argued for the superiority of cryotherapy in his important paper on Prophylaxis. Unfortunately, I found his argument unpersuasive. I believe that regardless of the modality that produces the chorioretinal adhesion the key element is treatment to the full circumference from the ora serrata extending posterior and not to areas of lattice alone. Since there is a high rate of giant retinal tears and these are generally not associated with the lattice pathology, it is no surprise that the lattice treatment approach would fail using either cryotherapy or laser. In the past I have also used scleral buckle with good success. Bottom line, A randomized trial would be helpful, but while we would like strong evidence (rather than strong opinion) to determine the best approach, prophylaxis is indicated and Dr Stickler agreed with this in my short conversation with him.

I do not think that treatment is without risk or that it prevents detachment in all cases, rather the risk of 7% bad outcome is better that 70%. Nontheless there remains a large group of ophthalmologists who do not treat preventatively. In adults, they can monitor the eyes for symptoms and perhaps they can get in quickly often before the visual potential is lost. I think regardless of the personal position that the physician must present the opportunity for treatment and ideally a copy of the Snead Paper (
Alan Ang, Arabella V. Poulson, Sandy F. Goodburn, Allan J. Richards, John D. Scott, Martin P. Snead, Retinal Detachment and Prophylaxis in Type 1 Stickler Syndrome, Ophthalmology, Volume 115, Issue 1, January 2008, Pages 164-168) After prophylaxis, I still monitor the patient on a 3-4 month basis.

Even more important than the controversy about prophylaxis is the sad situation in which some Ophthalmologist have never heard of this condition and even some Pediatric Ophthalmologists and Retina Specialists remain confused about Stickler Disease. Their patients go undiagnosed and untreated. Pediatric Ophthalmologists and Geneticists need to identify these patients and send them to experienced retinal specialists. My favorite summary about Stickler Disease is in the NIH GeneReviews.  Also another useful resource is Genetics Home Reference.  I will need to write more later about this very important topic, so I will call this part 1.





05 November 2010

The Current List of Publications for 2010 (MJ Shapiro)

These are papers that have been published or accepted for publication:
It has been an honor to participate in these papers and a real opportunity to review the literature and think about the topics. I would like to thank all the authors that worked with me.

1. Treating uveitis-associated hypotony with pars plana vitrectomy and silicone oil injection.Kapur R, Birnbaum AD, Goldstein DA, Tessler HH, Shapiro MJ, Ulanski LJ, Blair MP. Retina. 2010 Jan;30(1):140-5.

2. Torpedo maculopathy at the site of the fetal "bulge". Shields CL, Guzman JM, Shapiro MJ, Fogel LE, Shields JA. Arch Ophthalmol. 2010 Apr;128(4):499-501.

3. Progression of type 2 to type 1 retinopathy of prematurity in the Early Treatment for Retinopathy of Prematurity Study. Christiansen SP, Dobson V, Quinn GE, Good WV, Tung B, Hardy RJ, Baker JD, Hoffman RO, Reynolds JD, Rychwalski PJ, Shapiro MJ; Early Treatment for Retinopathy of Prematurity Cooperative Group.
Arch Ophthalmol. 2010 Apr;128(4):461-5.

4 Final Visual Acuity Results in the Early Treatment for Retinopathy of Prematurity Study. The Early Treatment for Retinopathy of Prematurity Cooperative Group*
Arch Ophthalmol. 2010;128(6):(doi:10.1001/archophthalmol.2010.72). Available On-Line

5. Optical Coherence Tomography of Nasal Sliding of the Retina and Temporal Arcades in Retinopathy of Prematurity Hoang, Quan V.; Chau, Felix Y.; Blair, Michael P.; Shapiro, Michael J. Retinal Cases and Brief Reports., doi: 10.1097/ICB.0b013e3181d4271b

6. Anomalous Retinal Vasculature in A Patient With A History of Aortic CoarctationHoang, Quan V.; Blair, Michael P.; Shapiro, Michael J.Retinal Cases and Brief Reports., POST AUTHOR CORRECTIONS, 17 February 2010doi: 10.1097/ICB.0b013e3181cc211e


7. Fluorescein Angiography of Recurrent Retinopathy of Prematurity after Initial Intravitreal Bevacizumab Hoang, QV, Kiernan, DF, Chau, FY, Shapiro, MJ, Blair MP. Archives of Ophthalmology, 2010;128(8):1080-1081. doi:10.1001/archophthalmol.2010.145

8. Laser Photocoagulation at Birth Prevents Blindness in Norrie Disease Diagnosed Using Amniocentesis Chow CC, Kiernan DF, Chau FY, Blair MP, Ticho BH, Galasso JM, Shapiro MJ Ophthalmology. 2010 Jul 8. 

9. Peripheral Retinal Nonperfusion in Septo-Optic Dysplasia (De Morsier Syndrome): Daniel F. Kiernan, MD1,Omar Al-Heeti, BS1Jeremy Keenan, MD, MPH3Steven J. Lichtenstein, MD4Michael P. Blair, MD1,2Ekaterini T. Tsilou, MD5, Michael J. Shapiro, MD1,2Archives of Ophthalmology (Accepted)

10. Effects of Green Diode Laser in the Treatment of Pediatric Coats DiseaseMichael J. Shapiro, M.D.1,2Clement C. Chow, M.D.1Peter A. Karth, M.D.3Daniel F. Kiernan, M.D.1Michael P. BlairAmerican Journal Of Ophthalmology (in press)

11. Medical radiation exposure and risk of retinoblastoma resulting from new germline RB1 mutation, Bunin GR, Felice MA, Davidson W, Friedman DL, Shields CL, Maidment A, O’Shea M, Nichols KE, Leahey A, Dunkel IJ, Jubran R, Rodriguez-Galindo C, Schmidt M, Weinstein JL, Goldman S, Abramson DH, Wilson MW, Gallie BL, Chan HSL, Shapiro M, Cnaan A, Ganguly A, Meadows AT. Int J Cancer,

12. Neovascularization after Nonaccidental Trauma. DF Kiernan, MP Blair, MJ Shapiro, Ophthalmology (accepted)


13. In utero diagnosis of Norrie disease and early laser preserves visual acuity. Kiernan DF, Blair MP, Shapiro MJ. Arch Ophthalmol. 2010 Oct;128(10):1382. No abstract available.
PMID: 20938020 [PubMed - indexed for MEDLINE] Letter October 2010

14.Acquired Vasoproliferative Retinal Tumor: A Late Sequela of Retinopathy of Prematurity.  CC Chow, MP Blair, MJ Shapiro.  Archives of Ophthalmology. (Accepted )

15. Multiple Retinal Holes and Peripheral Nonperfusion in Muscle-Eye-Brain Disease. Hoang, Blair, Ramani, Galasso, Shapiro. Accepted to Arch Ophthal. May 2010.